Brief scale for benzodiazepine detox?

Posted
by Words Matter Words Matter, BSN, RN Member Nurse Student

Specializes in Psychiatric Mental Health, Addiction, RN-BC, CARN. Has 7 years experience.

I am just curious if anyone is aware of a brief benzodiazepine withdrawal assessment tool, like the CIWA-A. The CIWA-B just has too many questions! Many of our nurses use the CIWA-A because our only two options are that or COWS which of course is completely unrelated. Thanks in advance!!

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 20 years experience. 4 Articles; 4,577 Posts

Well the two scales are different for a reason. But types of detox are different and have some different and some similar symptoms . Still CIWA - B is not that cumbersome if you really know how to assess a patient. A CIWA - B takes less than 5 minutes to perform.

Hppy

Luke79AU

Luke79AU

Has 6 years experience. 9 Posts

Please remember that benzodiazepine withdrawal is a far more complicated process than alcohol. Trying to reduce a patient to zero in 7 to 10 days is cruel and ineffective. Some especially notorious benzodiazepines, like alprazolam (Xanax) may take a month or more to withdraw from. 

The rule is to always switch to a long acting benzodiazepine, like diazepam, and reduce from there. This is because long acting benzodiazepines are significantly easier to withdraw from. In many patients taking short, and very short acting benzodiazepines, rebound anxiety can occur between doses, and doctors will sometimes increase the dose, adding to a greated dependence/addiction (same thing).

Do it slowly. It's not like alcohol, where we can break the physical addiction in 5 to 7 days. It's far more drawn out, especially if higher doses were taken, like the equivalent of 30mg diazepam per day, or higher. If you are really interested, read some research articles on flumazenil treatment for post-benzodiazepine withdrawal sicknes.

This is a special interest of mine. To date, this tool is the most accurate benzodiazepine converter I have found (https://clincalc.com/benzodiazepine/)

Edited by Luke79AU

Words Matter, BSN, RN

Specializes in Psychiatric Mental Health, Addiction, RN-BC, CARN. Has 7 years experience. 21 Posts

4 minutes ago, Luke79AU said:

This is a special interest of mine. To date, this tool is the most accurate benzodiazepine converter I have found (https://clincalc.com/benzodiazepine/)

Thanks - this is a great tip. I absolutely agree regarding the importance of a slow taper. My original intention in this post was to learn from others what tool they may use to document benzo withdrawal assessment. The response of our informatics nurse to my inquiry of adding the CIWA-b as an option in our EMR program was it is too long. Only COWS and CIWA-ar have been programmed in our EMR, along with a comments section. Recently, I printed the attached CIWA-b and keep it on the patient's chart, note this in the comments section that CIWA-b is appropriate for benzo detox, and I document a narrative of my findings in the IPOC notes noting the written assessment on the pt chart. And Hppy is right, the assessment doesn't take very long. The charting is what takes forever - 10 minutes of charting for a 5 minute assessment! Guess I'd better take some typing courses!!

benzodiazepine_withdrawal_scale_ciwab_dassa[1].pdf

Luke79AU

Luke79AU

Has 6 years experience. 9 Posts

10 minutes ago, 760marie said:

Thanks - this is a great tip. I absolutely agree regarding the importance of a slow taper. My original intention in this post was to learn from others what tool they may use to document benzo withdrawal assessment. The response of our informatics nurse to my inquiry of adding the CIWA-b as an option in our EMR program was it is too long. Only COWS and CIWA-ar have been programmed in our EMR, along with a comments section. Recently, I printed the attached CIWA-b and keep it on the patient's chart, note this in the comments section that CIWA-b is appropriate for benzo detox, and I document a narrative of my findings in the IPOC notes noting the written assessment on the pt chart. And Hppy is right, the assessment doesn't take very long. The charting is what takes forever - 10 minutes of charting for a 5 minute assessment! Guess I'd better take some typing courses!!

benzodiazepine_withdrawal_scale_ciwab_dassa[1].pdf

That's great to hear. That test looks reasonably impressive to me. I'm just a little concerned that it concentrates too much on symptoms of autonomic instability. At this point in withdrawal, most symptoms will be psychological. Feelings of "depersonalisation" often arise, and I see no mention of that. If I find a more comprehensive test, I will post it. I think the most important thing is to listen to the patient. Believe me, they are not getting "high" by doing a slow reduction. 

Orion81RN

Has 7 years experience. 962 Posts

On 11/14/2020 at 12:55 AM, Luke79AU said:

That's great to hear. That test looks reasonably impressive to me. I'm just a little concerned that it concentrates too much on symptoms of autonomic instability. At this point in withdrawal, most symptoms will be psychological. Feelings of "depersonalisation" often arise, and I see no mention of that. If I find a more comprehensive test, I will post it. I think the most important thing is to listen to the patient. Believe me, they are not getting "high" by doing a slow reduction. 

1 month is not a slow taper. I’m in month 16 of tapering. Finally down to 6mg Valium a day, and the withdrawal still sucks. The depression and not being able to experience joy at all is awful. Benzo withdrawal is a horrid horrid experience and too often not one many of us feel we can live through.  

Words Matter, BSN, RN

Specializes in Psychiatric Mental Health, Addiction, RN-BC, CARN. Has 7 years experience. 21 Posts

45 minutes ago, Orion81RN said: I’m in month 16 of tapering. Finally down to 6mg Valium a day, and the withdrawal still sucks. The depression and not being able to experience joy at all is awful. Benzo withdrawal is a horrid horrid experience and too often not one many of us feel we can live through.  

Thank you for sharing your experience. If you don’t mind my asking, what was your benzodiazepine daily use, and what was the starting point of taper? I had a patient recently propose to his psychiatrist using the Ashton Method for tapering. Is this the model/schedule you are using, or is there another resource informing your specific taper?

Orion81RN

Has 7 years experience. 962 Posts

12 minutes ago, Words Matter said:

Thank you for sharing your experience. If you don’t mind my asking, what was your benzodiazepine daily use, and what was the starting point of taper? I had a patient recently propose to his psychiatrist using the Ashton Method for tapering. Is this the model/schedule you are using, or is there another resource informing your specific taper?

4mg Xanax 13 years. Yes, using the Ashton Method personalized to my symptoms. Finally finally finally found a doctor willing to help. I can’t even begin to describe the harm “experts” do to benzo patients. There is zero reason a benzo taper shouldn’t be patient specific and loooong if needed. You do, however have everything to lose. Thank you for being an advocate for patients. You need to step up the knowledge though, watch the symposiums recorded in the last few years and listen to patients first and foremost. We are not lying about our withdrawal symptoms being this long and this debilitating. 

Luke79AU

Luke79AU

Has 6 years experience. 9 Posts

A method not used often, is using flumazenil in a similar way that naltrexone is used for opioid post-acute symptoms. Benzodiazepines cause most withdrawal problems via the benzodiazepine receptors. Flumazenil can be used in a similar way to naltrexone, "resetting" the receptors.

Personally, I crashed cold turkey from about 1 year of 2mg to 4mg alprazolam (Xanax - please use drug names, not product trademark names) per day. I was also taking nefazodone, a fairly potent 3A4 inibitor, which raises levels of 3A4 substrates and partial substrates (many drugs, including alprazolam). 

The first week was absolute hell, but it continued to be severe for some time, and I didn't feel right for a few months. I could have received flumazenil at 1 week after ceasing alprazolam, which would have led to a far better outcome. You may experience difficulty finding a practitioner who will provide this service. If I had to withdraw again, I would acquire the drug myself, and run a slow infusion. From what I read here, I'd much sooner choose the one week of hell, and then the rapid detox. Failing that, I'd definitely switch immediately to diazepam, then taper that down, remembering that 1mg of alprazolam is closer in equivalance to 20mg of diazepam, than 10mg, although being quite different makes comparison challenging. Many doctors fail to recognise alprazolam's potency.

Earlier on, I had to withdraw from several  months of 30mg diazepam per day. This was attempted on a rapid taper (5mg per day) by an idealistic doctor. That, of course, was very unpleasant, and failed. I withdrew successfully over 3 or 4 months with a experienced doctor. It wasn't all fun times, but it was significantly easier than alprazolam. Short-acting benzos are always worse, but the triazolo and imidazolo (most that end with "lam") are far more problematic than most benzodiazepines, which belong to the 1,4 class.